Painkiller intake and problematic health literacy in sport and music students - A cross-sectional study

Previous works have suggested a high prevalence of painkiller intake (PI) among sport students but also improved health literacy (HL) for sports-active students than for sports-inactive students. Since health-related content also forms part of the sport science curriculum, the study focuses on these seemingly paradoxical results. Music students who are also physically active through their instrumental practice, who act in an area with increased PI and who have no health-related teaching content in their curriculum composed the comparison group. Therefore, this study investigated the prevalence of PI and HL in cohorts of sport (n = 222; 54.5% female) and music students (n = 89; 67.4% female) using a cross-sectional online survey in Lower Saxony, Germany. The hypothesis tests were validated by calculating frequentist and Bayesian statistics. The results show that 50.9% of sport and 28.1% of music students exhibit PI concerning their study programs, often for prophylactical purposes and in the presence of low HL levels. The weak negative correlation between PI and HL was not statistically confirmed and requires further research with improved test power. Regarding the possible health consequences of an inconsiderate PI, target group-specific prevention is indicated to increase general health awareness and HL.

To better understand the PI-related situation, it is worth contrasting sports and music settings.Comparisons between athletes and musicians reveal similarities, such as long-term physical demands for both groups, and differences, such as shorter professional careers and better access to professional health care for athletes in a high-performance context 15,16 .Sports and music differ in their causes of pain.In sports, the natural causes of an enhanced need for painkillers are manifold and encompass events such as trauma, injury, or general training overload [e.g., 8 ].In the musical setting, pain is generally caused by numerous constant repetitions or practice overload 6 .In this respect, there are fewer reasons, notably fewer acute reasons, for pain in the music setting.
The PI is not always linked to the sensation of pain.A more problematic type of PI is for prophylactic purposes, as dosages are not tailored to the specific pain sensation [e.g., 4,7,17 ].In the case of pain-related or prophylactic PI, there is inconsistent control over the dosage of PI [e.g., 12 ].Increased PI, whether in dosage or duration, represents a potential health risk [e.g., 18 ].Additionally, incorrect or unreflective PI can cause long-term health effects, such as functional and structural damage to the musculoskeletal system or acute and long-term organ damage, particularly affecting the stomach, kidneys, liver, and heart 19 .In summary, PI is also closely linked to health.
Promoting health is considered relevant in both sport and music education contexts.While addressing healthrelated educational content seems to be a new idea in higher education music institutions 20 , sport studies are characterized by the consideration of health-related content in the curriculum [e.g., 21,22 ].Thus, sport students should gain a theoretical and practical health-related capacity for action during their studies.The construct of health literacy (HL) can be associated with this idea.According to Sørensen et al. [ 23 , p. 3], HL "is linked to literacy and entails people's knowledge, motivation and competences to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention, and health promotion to maintain or improve quality of life during the life course." Research suggests that sport activity is beneficial for young people's overall HL.Thus, young people who are active in sports have better HL than inactive young people 24 .Additionally, study results suggest that HL promotion has a beneficial effect on the PI of college athletes 10 .In this respect, sport students should have an advantageous basis, and PI can be used as a concrete example of applying HL and reflective decision-making.
There is evidence to suggest that sports students exhibit increased PI, although their curricula cover healthrelated learning content.This seems paradoxical, as one would assume a negative relationship between PI and HL.Furthermore, it can be assumed that music students tend to take painkillers in the context of their studies, while their curricula forgo health-related content.According to the study objectives and the reported study results, it was hypothesized that: (H1) sport students take more painkillers than music students; and that (H2) sport students show better HL than music students.Since the connection between PI and HL cannot be clearly deduced, it is hypothesized that (H3) there is a relation between the two variables.

Study design
The study was designed as a cross-sectional online survey.The cross-sectional design offers the advantage of providing a current and economic overview of the relevance of PI and the connection between PI and HL in the defined target group.The data sampling procedure was restricted to all universities in Lower Saxony, Germany, offering sport and/or music studies.The survey period started in November 2022 and ended in February 2023.

Population
A total of 413 individuals began the online questionnaire, which included an informed consent statement.The final sample comprised 311 students (n = 222 sport students, n = 89 music students; 58.2% females), as only those participants who had completed at least 50% of the entire questionnaire and could be identified as sport or music students were included in the evaluation (see Table 1).The mean age of the participants was 23.61 years (SD = 3.59, range: 18-42 years), whereas sport and music students showed a comparable age structure, t(309) = 0.30, p = 0.76, d = 0.04, 1-β = 0.85.

Materials
The online questionnaire was administered using the online survey tool LimeSurvey 25 , which ensured complete anonymity for the participants.The survey included the following categories: (1) pain, including an indication of pain regions and the intensity of pain within the last seven days (4-point Likert scale; 0 = no pain, 3 = severe pain; adapted from the Regional Pain Scale 26 ); (2) PI, including study-related intake in general and study-related intake within the last year (dichotomous items whether intake was conducted or not), preferred agents (multiple choices of the most common active ingredients), sources of information about painkillers (multiple choices of information sources), and prophylactic use (dichotomous response, whether prophylactic use was conducted before exams or teaching or not) [cf. 8,13,17]; (3) HL (measured by the German short form of the European Health Literacy Survey Questionnaire HLS-EU-Q16 and evaluated by a sum score of 0-8 = inadequate, 9-12 = problematic and 13-16 = adequate HL 27,28 ); and (4) study-specific data (e.g., number of practical classes) and demographic characteristics.This study was approved by the institutional ethics committee (Carl von Ossietzky Universität Oldenburg, Drs.EK/2023/013), in accordance with the Declaration of Helsinki.Informed consent was obtained from all participants at the beginning of the survey.

Statistical analyses
The statistical analyses were performed using SPSS version 29.0 29 and JASP version 0.18.1 30 .Due to the existing data structure, nonparametric tests were used to check for potential differences in PI (chi-square test supplemented by odds ratio [OR] as an effect size [H1]) and HL (Mann-Whitney test supplemented by r as an effect size [H2]) between sport and music students.Additionally, a point-biserial correlation was used to analyze the relationship between PI and HL (H3).Since the study aims to evaluate the PI in sport and music studies, testing the first hypothesis is considered multiple testing based on five individual tests [cf. 31].For this reason, the significance level was adjusted using Bonferroni correction to avoid false positive statistical test results, leading to a level of p = 0.01.Following the recommendations of Büsch and Loffing 32 , the alternative hypothesis was verified in relation to the null hypothesis and how many times more likely the alternative hypothesis was to be true than the null hypothesis by calculating the Bayes factor.Using additional Bayesian statistics, the significance of the results can be increased compared to traditional statistical methods.Additionally, post-hoc power calculations were performed using G*Power version 3.1.9.7.software 33 .

Painkiller intake among students
Assuming a more prevalent PI among sport students [H1], we calculated the frequency of PI in the two student groups concerning intake in their studies in general (study-related prevalence) and within the past twelve months (one-year prevalence; see Table 2 for detailed information on the statistical tests).The PI prevalence results showed that, independent of the substance, sport students took significantly more painkillers during their studies (50.9%, n = 113) than did music students (28.1%, n = 25, p < 0.001, OR = 2.65).A comparable result was shown for the one-year prevalence: sport students (36.0%, n = 80) indicated a greater PI within the last year than did music students (21.3%, n = 19, p = 0.01, OR = 2.07).This means that, sport students have a more than two times greater risk of PI in the context of their studies than music students.The Bayesian statistics provided substantial (BF 10 = 3.60 for the one-year prevalence) to decisive evidence (BF 10 = 140.54for the study-related prevalence) to support the validity of the alternative hypothesis H1 in both cases [cf. 34].To conduct a differentiated hypothesis test for H1, a comparison of specific active agents that focused on the one-year prevalence and on the three most frequently named painkillers was performed: ibuprofen (29.9%, n = 93), paracetamol (10.6%, n = 33, and diclofenac (6.8%, n = 21).Moreover, sport students (34.7%, n = 77) tended to take significantly more ibuprofen than did music students (18.0%, n = 16, p = 0.004, OR = 2.42, BF 10 = 11.28).On a descriptive level, sport students also took more paracetamol (12.6%, n = 28) than did music students (5.6%, n = 5).However, this difference was not confirmed statistically (p = 0.07, BF 10 = 0.49), mainly focusing on the OR and the lower confidence bound, which indicates possible equality between the two groups [cf. 35].The same phenomenon was shown for diclofenac, indicating solely on a descriptive level that sport students (8.1%, n = 18) take more diclofenac than music students (3.3%, n = 3, p = 0.13, BF 10 = 0.23).Therefore, in terms of active ingredients, strong evidence for a more prevalent PI in sport students, confirmed by the Bayes factor 34 , was found only for ibuprofen.

Health literacy of students
A sobering picture emerges for the HL of the sport and music students.Here, 75.2% (n = 161) of the sport students and 79.3% (n = 69) of the music students indicated inadequate HL (see Table 3).A comparison of the two student groups (H2) revealed that sport students (median, short Mdn = 10.00,mean absolute deviation, short MAD = 2.00) did not exhibit greater HL than did music students (Mdn = 10.00,MAD = 2.00; U = 8857.50,p = 0.25, 1-β = 0.49, BF 10 = 0.23).Furthermore, the Bayes factor confirmed the equality of sport and music students' HL, providing strong evidence to support the null hypothesis [cf. 34].
Additionally, outside of hypothesis testing, the information provided by the students showed that more than half of the students (59.5%, n = 132 of the sport students and 59.6%, n = 53 of the music students) suffered from acute pain during the period surveyed (see Table 1).Most of the sport students (50.5%, n = 112) and almost half of the music students (49.4%, n = 44) reported pain in at least two body regions.There were differences in frequency and intensity between the sport and music students regarding the identified pain regions.While the sport students suffered comparatively more often and more intensely from pain in their legs and feet (W = 5074.00,p < 0.001, r = 0.45, 90% CI [0.32, 0.57]), the music students reported comparatively more headaches (W = 1865.50,p < 0.001, r = 0.48, 90% CI [0.34, 0.58]).Focusing on PI outside of hypothesis testing, prophylactic PI before exams was reported more by sport students (55.0%, n = 44) than music students (15.8%, n = 3, χ 2 (1, N = 99) = 9.47, p = 0.002, OR = 6.54, 90% CI [2.17, 19.61]).

Discussion
PI is a prevalent behavior for sport and music students, as more than half of sport students and more than a quarter of music students use painkillers during their studies.The PI prevalence of sports students is in line with the findings of the data collection from 2017 by Bumann et al. 8 and supplements it with a more precise one-year prevalence.Although the one-year prevalence is lower, PI and pain can be considered as a frequent side effect of sports studies.The data clearly show that taking painkillers is common even in the absence of pain.
Information on prophylactic use aggravates the extent of PI, particularly among sport students.Compared to findings on athlete behavior before sports competitions 4 , sport students showed event-related (e.g., exams) overuse of painkillers prior to the onset of pain.It is particularly striking that 47.5% of sport students take painkillers before regular teaching and thus in comparably low-threshold settings.Interpreting this result, students might feel under pressure at an early stage that breaks could jeopardize their study progress.In this context, Bumann et al. 8 show indicators for a cost-benefit analysis in the form of individual qualitative statements on dealing with pain.Whether this assumption can be applied to prophylactic PI needs to be tested in follow-up studies.Prophylactic PI can be considered particularly risky for health since there is no physical sensation to reference during intake.Thus, the signals that indicate limits of physical performance might be suppressed or easier to Table 3.].Therefore, these results can be considered indicators of inconsiderate painkiller use, particularly among sport students and a sufficient health-related capacity for action seems even more important.A general survey of the HL led to a sobering result.Although one would attribute an advantage to sport students compared to music students regarding their HL based on the integration of health-related content in the sports curriculum [cf. 21,22], both student groups indicate severe deficits.Since painkillers can lead to severe short-term and long-term physical damage if used without reflection 4,19 , unreflective use can be regarded as problematic and hazardous to health.Therefore, future studies should also include the individual problem awareness of PI.Without awareness of potential adverse health sequelae, this information can be used as a further indicator of insufficient HL.

HL level
There is weak evidence that HL increases throughout studies.Looking at the statistical data, we find a low positive correlation, and a large confidence interval accompanies the correlation coefficient.Therefore, these results must be interpreted carefully.Additionally, this effect does not apply specifically to sport students or their curriculum since a similar correlation can be found for music students.In this respect, studying sports specifically does not seem to promote HL.Interpreting this result, there could be an issue with the sender (lecturer) or the receiver (sport student).On the sender side, health-related content is potentially not conveyed sufficiently, and/ or the recipient may not see personal relevance.Curricular analyses in the context of school teaching research indicate a difference between curricula and practical implementation in the sport teaching-learning context 36 .Transferring this idea to a university setting is worth considering the existing inclusion of health-related learning content in teaching, which also considers the student's perspective.Although the data indicate a comparable initial level of HL, sport and music students differ in the causes of their pain and their PI behavior.Thus, subject specificity should be considered in the design of teaching-learning processes to support students in a more reflective PI and their HL [cf. 10 ].An HL-based decision of whether to take painkillers could require a consciously guided reflection process.The data can be interpreted as students downplaying PI or overestimating their physical resistance.In addition, their already low HL may not have been activated in the decision-making process.HL can be viewed as the result of an educational process since it would have to increase, for example, with increasing knowledge of health-related content or the motivation to address health-related topics in a self-referential manner [cf. 23].In this context, it makes sense to relate findings on optimistic self-referential errors about the harmfulness of smoking in young people 37 to sport and music students and painkillers.
A correlation between HL and PI cannot be shown statistically.Instead, a diffuse picture emerges, which must be discussed methodically.The results can be interpreted in two directions: (1) HL and PI are primarily independent, or (2) the operationalization of HL using a general HL questionnaire (HLS-EU-Q16 27 ) was too unspecific and not adequate for the setting of sport or music studies and painkillers.Therefore, an area-specific operationalization of HL or related constructs should be discussed.It would be conceivable to have a painkillerfocused subscale that goes beyond the use of medication-as mentioned in the HLS-EU 16 27 -so that the overall construct is represented in its breadth and is supplemented by a painkiller-specific interpretation.Additionally, the dose and specific intake indication represent essential information needed to better understand the PI of sport and music students.In addition, a general query about the perceived relevance of health-related topics for young target groups appears to be appropriate.
From a research methodological point of view, the results must also be critically classified.Despite validating the results using the Bayes factor, the statistical analyses are characterized by low test power.The present sample can be considered too small for detecting effects, so replication with a larger sample based on an a priori calculation of the required sample size is necessary.Nevertheless, considering the descriptive data, it is evident that PI and HL among sport and music students are problematic and should be further investigated.

Conclusion
Numerous students carelessly take painkillers and appear to be unaware of side effects and consequential physical damage.Additionally, we observed an openness to prophylactic PI, indicating an underestimation of the adverse effects of painkillers.Considering the poorly reflected PI, particularly among sport students, constructive and subject-specific painkiller prevention seems to be necessary.The goal of painkiller prevention would be a reduced and reflected use, as abstinence seems utopian.Prevention measures should take different starting points into account.On the one hand, this prevention approach would have to be suitable for people who need to be made aware of the consequences of unreflective and excessive PI.On the other hand, people who are aware of the health risks of excessive intake but who have no alternative course of action should also benefit.Increasing health-competent behavior could be seen as access.Despite the weak correlation between HL and PI, improving HL or related constructs could lead to a more reflective PI.To strengthen the compliance of young students, queries of needs and interests should be carried out in advance.The aim of all these efforts should be to enable students to study as painlessly and injury-free as possible and, in the event of pain, to conduct a health-friendly pain management. https://doi.org/10.1038/s41598-024-63127-3www.nature.com/scientificreports/

Table 1 .
General and pain-related characteristics of the sample.

Table 2 .
Differences in PI between sport and music students.